Peritonitis Priorities

transcript

Paul Finan

Department of Colorectal SurgeryLeeds General Infirmary

PeritonitisClassification

• Primary - often spontaneous and single organism

• Secondary - multiple organisms, perforations, leaks, ischaemia etc

• Tertiary - no organisms, disturbance in host immune response

Priorities in PeritonitisEarly Recognition

• Often classical clinical picture but….

• Beware of immuno-suppressed patients

• Elderly patients

• Post-operative patients with cardiac problems

• Unexplained failure to progress clinically

Peritonitis PrioritiesRadiological Support

• Plain films e.g. free gas or unexplained ileus

• Abdominal ultrasound – simple collections

• CT scanning – of particular value in the post-operative patient

• Labelled white cell scans

• MR imaging – no experience

Peritonitis on CT Scanning

Radiologist

Microbiologist

Anaesthetist

Nursing Staff Surgical Staff

Wound Care Specialists

Nutritional Team

Scoring Systems

An effort to quantify case mix and so estimate outcome

• APACHE – initially 34 variables

• APACHE II – reduced to 12 variables

• Sepsis Score (SS)

• Sepsis Severity Score (SSS)

Relationship Between APACHE-IIand Mortality

Prognostic Scoring Systems in Peritonitis

Comparison of APACHE II, APS, SSS, MOF and MPI, in 50 patients with peritonitis

• All scoring systems predicted outcome in univariate analysis

• APACHE II and MPI contributed independently in a multivariate analysis

• All patients with an APACHE II of >20 or MPI >27 died in hospital

Bosscha et al 1997

Source ControlSource Control Damage Limitation

Source Control

• Drainage of abscesses

• Debridement of devitalised tissue

• Diversion, repair or excision of focus of infection from a hollow viscus

Source ControlDrainage of abscesses

Surgical or non-surgical drainage governed by..

• Clinical state of patient

• Site of collection

• Extent of collection

• Underlying aetiology

Diverticular Abscess

Drainage of Diverticular Abscess

Non-surgical Drainage of Intra-abdominal Abscesses

A study of PCD in 96 patients with 137 abscesses accumulated over a 3-year period

• Successful resolution in 70% after a single procedure and 82% with a second drainage

• More often successful in post-operative abscesses.

• Poorer results with pancreatic abscesses and those containing yeasts

Cinat et al 2002

Non-surgical drainage of Intra-abdominal Abscesses

A study of 75 patients undergoing PCD of intra-abdominal abscess

• Successful treatment in 62/75 patients (83%)• Success associated with unilocular collections,

<200 mls., APACHE score <30 and accessible regions

Betsch et al 2002

Pancreatic Collection

Pancreatic Drainage

Source ControlDebridement of Devascularised Tissue

• Most commonly encountered in necrotic pancreatitis

• Removal of dead bowel

• Debridement of other necrotic intra-abdominal tissue

Source ControlManagement of the Source of Contamination

• Excision – appendicitis, cholecystitis

• Repair – perforated ulcer, early iatrogenic injury

• Diversion +/- excision – leaking anastamosis

NB These are the decisions that require experience

Damage Limitation

• Procedures at the time of surgery

• Decisions in the post-operative period

Peritoneal Lavage

Damage LimitationDecisions at the time of Surgery

• Management of the infective source

• Peritoneal toilet and removal of particulate matter

• Peritoneal lavage

• Drains

• Wound closure

VAC Dressing

Damage LimitationPost-operative Decisions

• Re-laparotomy

• Laparostomy

• Interval imaging

• Duration of antibiotic therapy

Re-laparotomy in Peritonitis

• Failure to progress clinically

• Prompted by radiological imaging

• Where viability is in doubt

• Failure to control source of infection

Relaparotomy for Secondary Peritonitis

Meta-analysis comparing planned relaparotomy and laparotomy on demand

• No randomised studies

• Non-significant reduction in mortality with the latter approach

• Evidence based on eight heterogeneous studies

Lamme et al 2002

Laparostomy

Abdominal wall cannot or should not be closed

• Major loss of the abdominal wall• Visceral or retroperitoneal oedema• If decision has already been taken to

perform a re-laparotomy• Likelihood of creating abdominal

compartment syndrome

Radiologist

Microbiologist

Anaesthetist

Nursing Staff Surgical Staff

Wound Care Specialists

Nutritional Team

Antibiotics in Peritonitis

• Consideration to source of infection and likely bacteria

• Fewer drugs for shorter periods of time

• A policy of reculture and change if necessary

• No clear benefit of a particular regimen in the Cochrane review (Wong et al 2005)

Peritonitis PrioritiesConclusions

• Multi-disciplinary approach

• Increasing role of the radiologist

• Emphasis on source control

• Need for correct decision at time of laparotomy

• Lack of trial evidence

Peritonitis Priorities

Documents